 To the McLean Centers and the University of Chicago Trauma Centers, 10th lecture in the series on ethical issues in violence, trauma, and trauma surgery. Our speaker today is Dr. Bradley Stalback. Dr. Stalback is a child psychologist and an associate professor of pediatrics here at the university. Dr. Stalback serves as the clinical director of a program called Healing Hurt People Chicago. I hope you've picked up this beautiful necklace that, you know, it's available out back, but I'm giving a few to my family tonight. What's that? If you want some jewelry to go on it, go to Project Fire. And get some. Healing Hurt People Chicago, which is a trauma-focused hospital-based violence intervention program that's implemented in pediatric emergency settings. The Healing Hurt People program is a partnership between the University of Chicago Comers Children's Hospital, the Trauma Department of Stroger Hospital at Cook County, and the Center for Nonviolence and Social Justice at Drexel University's School of Public Health. That's Drexel in Philadelphia. Dr. Stalback received his PhD in psychology from the University of Colorado, completed his internship in fellowship in clinical psychology at Laura Beda Children's Hospital here, and also co-founded the Laura Beda Child Trauma Center and directed the center until he moved from Laura Beda to the university in 2013. In 2016, Dr. Stalback became the principal investigator on a project called the University of Chicago React REACT program, Recovery and Empowerment After Community Trauma. This program created a new community treatment and service center in the National Child Traumatic Stress Network and was started with a $2 million five-year federal grant from the U.S. Substance Abuse and Mental Health Services Administration. In 2017, Dr. Stalback received the Senior Distinguished Leader in Community Service and Advocacy Award from the University of Chicago. Dr. Stalback's research has focused on developmental trauma in urban youth with particular concentration on cumulative trauma in young children and the connection between poverty and urban trauma. He also has studied developmental trauma in children and young adults affiliated with armed groups. Dr. Stalback's talk today is entitled Healing Hurt People Chicago, Supporting Trauma Recovery in Patients Injured by Violence. Please join me in giving a warm reception to Dr. Stalback. Thank you very much. It's great to be here. I am grateful for this series, which has been excellent. I haven't been able to come to every lecture, but the ones I have been able to attend have been really great, so I appreciate you all being here today. I am representing many people here today, so the work that I'm describing involves a lot of other people, not just me. One of the most important of whom is here today, Reverend Carol Reese, who is Program Director of Healing Hurt People Chicago. And she will be speaking here with Dr. Kimberly Joseph in two weeks, so don't miss that. In addition to all of the folks that were on that first slide, we also have a team of peer leaders who are part of our program. And then our Project Fire team. I'll talk a little bit more about Project Fire if you're not familiar with it later on in the talk. And I want to start with another way of communicating about the violence that's going on in our city, and this is by one of our peer leaders, Dantro Blake. I think I'll even listen up without this one, though. Hey, too much going on in my city, man. I'm going to let y'all know how I feel, though. I think I'm going to let y'all know how I feel, though. Who's city is this anyway, right? It's my city. Dantrell says his city. If all part of the city, we all bear responsibility for trying to do something about what's going on in our city. I think a lot of times these problems get viewed as being about somebody else, somebody different. From many of people who call this their city. So what I'm going to talk about today is, do we have an ethical obligation to treat the psychological, emotional, and spiritual injuries that our violently injured patients have sustained? And the way that I'm going to talk about that is by first talking about traumatic effects of violent events, how violence and complex trauma shape development, developmental trauma in our Healing Heard People Chicago patients, structural violence, the economics of hospital aid's violence intervention programs, the Healing Heard People model, and finally our experience with the Healing Heard People model over the last four-ish years. So how do we know that our patients have psychological injuries from the violence they've experienced? So one way we know is common sense, right? If anyone has ever experienced a life-threatening situation, lived through a situation in which they were seriously harmed, injured, assaulted, you know that those experiences stay with you, preoccupy you, maybe take over your life for a period of time. So it's simply common sense that getting shot, for example, is going to mess with you, right? It's going to put you through some changes. It's going to make your life difficult in a variety of ways. We also know that our patients are injured because we have decades now of theory and research on the psychological impact of traumatic experience. So I'm going to try to talk about that briefly. And in talking about what happens in a traumatic experience, I'm going to highlight the differences from other kinds of experience and how we deal with that. So in typical conditions, we observe our environment, we observe stimuli, we take in information about what we're observing, we interpret that information so we make some judgment about what it means. We process it, that is, we take our interpretation and combine it with everything else that we have in there. We evaluate what we should do about it, if anything. We make a plan of what we're going to do about it, and then we act. And this is a process that we go through, moment to moment, second to second. These are things that happen very, very, very quickly, right? When you're in a traumatic situation, you have to think about the different parts of the brain and what happens in them. So a part of the brain that's very relevant to our response to trauma is the amygdala. The amygdala is involved in the interpretation of the emotional significance of stimuli. People talk about it as the alarm bell. It's the thing that says, pay attention, this is important. And in most circumstances, the amygdala says this is important and then the information gets sent to the hippocampus where we make sense of it. It's the part of our brain that we use to think about things and to put it together with what else is in there. When the amygdala is firing rapidly, as it would be in a situation of constant threat or serious threat, the hippocampus is actually shut down. So information doesn't get integrated into pre-existing schemes the way it does in non-traumatic circumstances. So what happens is we act, I mean we observe, but we immediately interpret. So we make meaning out of what we're observing and we act on it. And all those other steps that happen in normal situations or non-traumatic situations are out of the loop. And the way that we tend to act in traumatic situations is fight, flight or freeze. So traumatic memory does not get processed or interpreted in the way that other memory does. And instead it gets stored in visual or somatosensory that includes affect, affective impressions. So basic assumptions here, number one, traumatic experiences are those which overwhelm an individual's capacity to integrate experience in the normal way. And so what happens in traumatic experiences is that rather than an integrative response, what we have is a dissociative response. And following that, if the integration of that information and that experience doesn't occur, those experiences get split off by that dissociative process. And an individual alternates between functioning as if the trauma is still occurring and functioning as if it never happened. So we're responding as if we're under constant threat or responding as if there's no danger. And so although this process often keeps traumatic memories and associations inaccessible to consciousness, it keeps it out of our awareness, those experiences still have power to shape an individual's daily functioning and behavior. The simplest, most straightforward example of this is PTSD, post-traumatic stress disorder. Post-traumatic stress disorder, what you have is an event, and all the symptoms in post-traumatic stress disorder are linked to a specific discrete event in time, right? And then you have symptoms that fall into one of these categories, re-experiencing, numbing, hypervigilance, and avoidance. PTSD is a relatively common kind of problem. There's a lot of disagreement about whether the D should even be in there, whether this is a disorder or whether this is a normal set of responses to traumatic experience, but we'll use the D because that's what it says in the book. Most people who have PTSD or who are diagnosed with PTSD never receive any kind of treatment at all for it. So the prevalence of PTSD in the general population is around 8%. Among African-Americans, it's slightly higher, around 9%. Among urban low-income African-Americans, it's around 22%. And among African-American patients reporting significant traumatic events, it's around 33%. Reverend Reese did a study with her colleagues at Sturger Hospital where they did screening for PTSD with outpatients in the trauma unit. And so they screened 307 patients and family members, and they simply asked these four questions. So questions reflecting re-experiencing, avoidance, hyperarousal, and numbing. The prevalence in that study based on that screen was 42% had positive screens for PTSD. That included not just 43% of those who had experienced a traumatic injury, but the same percentage basically of their family members. And if you've ever been in a situation where your child was injured or your spouse was injured, you know that that can be very traumatic, sometimes even more traumatic than being the injured part of yourself. One of the things that they found also that's very important for what we're talking about today, patients with gunshot wounds were 13 times as likely as those with falls and twice as likely as those in a motor vehicle crash to have a positive screen. So our gunshot patients are very, very highly likely to have PTSD. In Healing Her People, we have data from our colleagues in Philadelphia. With adults, they found 75% met full criteria for PTSD. With children, they found about 66% were positive for PTSD. And in our own kids here, we found the same percentage that they found in Philly, about 65% who were positive for PTSD. So there's another way we know that our patients are injured by the violence that they experience, and that is that they tell us. 17-year-old Diamante Lee was shot five times one night, just over a year ago. He's been extra vigilant ever since. I watch everything, like every little thing. There's somebody walking behind me, and they just been walking around for like a past couple of minutes. I stopped, and they were buggerheaded me, so I just, you know, wouldn't be afraid as much. He had just finished playing basketball at the park, he says, when a man randomly approached him. A couple of seconds later, he was reaching for something. I didn't know where it was. So it just froze up. He just started shooting. Once he started shooting, I just ran. As I was running, they were just hitting me, but I just kept going. I was asking myself, like, why this happened to me? But the best thing for me not to do, I just didn't panic. I was just trying to breathe and stay calm. What were you most worried about at that moment? Dying, really. But I wasn't. I don't give up. Being through something like this can really affect your mind. You think so many things that a person my age should be thinking about. It's really scary. What was the scariest part for you? I mean, jumping up in the middle of the night, cold sweats, yelling, screaming. It was like just hearing the sound of the gun, of you being shot over and over. It's scary. It really bothers you. You could actually hear the sound? Yeah, like dance. After you wake up from it, your ears just ring. Diamante has worked with counselors at Cook County Stroger Hospital since he was shot to deal with the symptoms of traumatic stress. But he still doesn't always feel safe. One day I went up there just to see how I feel. And I actually stepped in the spot where I was shot. And I was just like, no, I ain't coming back anymore. I had cold chills. I was shaking. And it just made me think about that night. So I'm like, I gotta go. Despite being there? Yeah. So you don't go to that park anymore? No. So based on our common sense, our theory, our research and what our patients tell us, I think it's fair to say that they have these injuries. And that if they present to us with a gunshot wound or a stab wound, it's very, very highly likely that they have these injuries. And it would make sense to assume that they have these injuries and act accordingly rather than to wait for them to tell us. So if a patient comes in to the trauma unit and they have a gunshot wound to the lung and they have a gunshot wound to the ankle, right? We don't just pay attention to the bullet in the lung because the one in the ankle isn't going to kill them right away, right? We treat both injuries. These injuries are just as important and maybe more important in terms of injury recidivism and mortality than the bullet in the ankle. And yet in most contexts we simply ignore them. We don't even check to see if they're there or not. So that's fair to say with a single episode trauma, it's highly likely that someone is going to be traumatized, right? This is some research that we did a few years ago with the Burn Center here. This is children who had been burned and we were able to ask them or their caregivers about trauma responses. And we found that 70% of the children had clinical levels of trauma, traumatic stress symptoms. Any thoughts about what would predict that? Who had symptoms? Thank you, Dr. Masal, of course, as previous trauma. That's exactly right. That was the only thing actually that statistically significantly predicted who was having symptoms or the level of symptoms. And two-thirds of the children had history of a prior trauma exposure, including over half of them who'd experienced two or more different types of traumatic stress prior to being burned. So as a group, they averaged over two and a half types of traumatic stress, including the burn. And this tells you what those different types are. And most of them are related to violence. So how many are familiar with something called the Adverse Childhood Experiences Study? That's pretty good. That's like about 30%, I think, I saw hands. So the Adverse Childhood Experiences Study was published 20 years ago. And what they did, and this was in a middle class, mostly white, employed population in San Diego, and they asked people if they had had any of these different types of adversity in childhood, up to age 18. Physical abuse, emotional abuse, sexual abuse, having someone with a substance problem in the household, having a household member incarcerated, someone who's chronically depressed, mentally ill, institutionalized or suicidal in the household, domestic violence, loss of a parent or separation of parents, emotional neglect and physical neglect. And what they found is that having these experiences in childhood increased the risk for about every bad outcome that they looked at, including depression, drug addiction, alcohol use, abuse. But not just these behavioral, emotional outcomes, also health outcomes, right? So that includes obesity, cigarette use, general health problems, and actually all the leading causes of early death and adulthood. So what they have, based on the ACEs study, is a model that says when we deal with adversity in our childhood, it disrupts our development, and that leads to social, emotional, cognitive impairment. Or as we're talking about today, not necessarily impairment, but adaptation. And then we adopt health risk behaviors to deal with that. That leads to disease, disability, school problems, and eventually early death. So what we have is a cycle where we have the experiences, we adapt to them. Our adaptations increase our risk for more bad stuff. That leads to chronic levels of stress without adequate resources to deal with and mitigate the impact of that stress, which leads to longer-term adaptations that impair functioning and increase long-term risk for re-exposure, and it goes round and round and round. In our patients in Philadelphia, they found 56% reported three or more ACEs, 35% five or more, and almost 19% seven or more. And that's out of 10. In the ACE study, they found kind of a magic number effect for four. If you're four or above, your risk is exponentially increased for everything. It's important to remember that this does not include the kinds of traumatic stress that we're talking about our patients dealing with, the things that bring them to us are not even included in this. Among our patients, for whom we have this data, 70% reported three or more, 39%, four or more, and 22%, five or more. So the other thing we learned from the ACEs study is that trauma does not happen in isolation. If you have one type of adversity or trauma, you've likely had more than one. So despite this fact, most of our different types of adversity or trauma are dealt with as if they happen in isolation. So we have different interventions for different types of trauma, for domestic violence or sexual abuse or assault, or now the one I'm talking about today for community violence. In fact, things don't tend to occur that way in nature, right? It's much more likely for someone who's had one to also have been exposed to others. That's true for the kids we work with, and it's true for most people. This is data from 128 patients that we identified. Average age is around 14 years, eight months. About three quarters of these kids have been shot. 96% report history of prior exposure to at least one traumatic stressor. And that's one type. That's not one event, right? Any of these types could be many events. 57% of those with injuries reported history of a prior violent injury. Oftentimes, those are less severe injuries. It may not be level one trauma injuries, but they're injuries for which they went to the hospital. 91% said they heard gunshots in their neighborhood. It's almost like when you ask that question, they look at you like what is wrong with you. You're asking me if I hear gunshots in my neighborhood. Sort of like asking when you go outside, is there air? But more important to me than that is the next one there. 87% of our kids had lost a family member or close friend to violence. The levels of loss that our kids are carrying around with them are really staggering. And if you think about, again, going through one loss like that, going through the violent death of one person close to you and what that does to you and what that does to your life, and then think about going through that over and over again. So they come to us with a violent injury. Oftentimes, it's not the only time something like this has happened. And oftentimes, it's not even the most important to them. These are some trauma history timelines that give you an idea of some of our clients and what they have experienced in their life. So what this shows you is different types of trauma and adversity, and then the ages they were when these things happened to them. So you can see that there are some things that are sort of the ongoing context of their lives, and then there are discrete events that they're dealing with. When we work with people in a trauma-informed way, ideally what we have is in our head an understanding of how their lives look from this perspective. When you have this kind of understanding of what someone has dealt with in their life, it can oftentimes be extremely helpful in making sense of what they're doing or saying. This is another one of our clients, and I just highlight on here. The black line is when he says he started feeling suicidal when he was six years old, and then the red line is when we put him in the hospital for five days when he was 17. So probably he told somebody that he felt suicidal, and we put him in the hospital, and then we spent a bunch of money to put him in the hospital, and then we did whatever we did to control his behavior while he was in the hospital, and then we sent him away with nothing. That's how our system currently operates. So when people are faced with not just a single traumatic kind of experience, but multiple types of trauma diversity and cumulative trauma in a developmental context where there's very little safety, protection, comfort, that doesn't just become the trauma response. It becomes the way of responding to everything, right? So these slides with the road, they come from a great social worker in Anchorage, Josh Arvidson, and so the road closed I think is just a brilliant metaphor for what this kind of stuff does to us. So when we talk about complex developmental trauma, we're talking about not just single events. We're talking about exposure to multiple forms of violence and other potentially traumatic stressors in the context of attachment behavioral systems that are unable to provide protection, care, and comfort. Now, some people like to say that the problem is bad parents, right? It's one of the peas. The mayor talks about his peas. Have you ever heard the mayor talk about his peas? One of his peas is parenting. No one ever talks about what those parents have dealt with and what they're dealing with, right? Now, you don't hear him talk about traumatized parents, right? But this is not to say that these are bad people or bad parents, but that the systems can't do what they're designed to do, what they're intended by nature to do, which is to provide protection, care, and comfort. So the focus is on cumulative trauma and the developmental context in which the exposure trauma occurs rather than on discrete episodes of trauma. And when you have this kind of complex trauma that you're dealing with as you grow, it shapes how you develop in a lot of ways. And some of the key ways are the ability to modulate, tolerate, or recover from extreme affect states, regulation of bodily functions, the capacity to know what's happening inside you, the capacity to describe what's happening inside you to other people, the capacity to perceive threat, very important for our kids, including reading of safety and danger cues, self-protection, self-soothing, the ability to initiate or sustain goal-directed behavior that is to have a goal and make a plan for how to work towards it, the coherent self or identity, and the capacity to regulate empathic arousal. That is how do I manage it when I am aware that someone else is feeling something? So these are all developmental capacities that we need in order to function day to day, in order to relate to people, in order to live, love, and be loved, right? When those are shaped by violence, it makes it hard. And we have now just the beginning of the research evidence to support the idea that developmental trauma in childhood is a risk factor for being affiliated with gangs or street organizations, or for engaging in the kind of behavior that people who are affiliated with those groups engage in. So this is some data from a colleague, Eddie Bocadegra, where he asked kids that he was working with who were affiliated about different trauma that they didn't expose to, and he found that they averaged almost 13 different types of trauma and adversity, that the average age of the first trauma was six years, and they all had experienced physical abuse, they all had witnessed community violence, many had witnessed sexual assault, like our kids, almost 90% had lost a loved one to violent death. So it would make sense that their development would not go the same way that mine did, for example. This is just a quote from one of those children who said, the hardest part about seeing my best friend die was watching him trying to breathe while he was turning blue and watching all of his blood run down onto the sofa, which happened when he was 13 years old. That was the third homicide that he had witnessed. This is his trauma history. So on the left are the different types of trauma adversity he experienced. On the right is the age that he was when they happened. This is the same information, but again in the trauma history profile that gives you an idea of what else was going on in his life. The black line is when he first performed actions on behalf of a street organization, that is when he held a gun for his brother when he was eight years old. This is the definition of a child soldier that the United Nations uses. A child soldier is any person under 18 years of age who is part of any kind of regular or irregular armed force or armed group in any capacity, including but not limited to cooks, porters, messengers and anyone accompanying such groups other than family members. The definition includes girls recruited for sexual purposes and for forced marriage. It does not therefore only refer to a child who is carrying or has carried arms. Our kids, now this is a small number of our kids who we're actually able to get this information from. But for those who tell us that they have been affiliated with a street organization, the average age when they first affiliated was 10 years, 11 months. And the range was eight years old to 15 years old. The average age when they each first held a gun, 11 years, three months. There's some work that's beginning to get done now looking at gang membership or affiliation with a street organization as a form of labor trafficking. It's relatively recent that sex trafficking is viewed as something that a child is a victim of rather than the child committing a crime. It's illegal now or is no longer legal in Illinois to charge a child with solicitation, with prostitution. The types of services performed by juvenile gang members from selling and transporting drugs to engaging in crimes against persons and weapons crimes fall under at least one of the international labor organization's enumerated worst forms of child labor. So what does it matter anyway if we look at our kids as child soldiers or we look at them as criminals, right? We love to lock people up. We love to lock children up. We lock children up like no other place in the world. Many of these children are classified by statute as adults. That is that based on what we have accused them of doing, what we alleged that they did, we treat them as adults. And they are tried in a legal system that is intended for adults. Have you ever heard of Bryan Stevenson? Anybody heard of Bryan Stevenson Equal Justice Initiative? He spoke here last, I think it was MLK Day, wasn't it? I don't know. He was here last year. Anyway, he tells a story that he had a client and his client was charged with murder. And he said, your honor, if my client is going to be charged as an adult, I would like him to be charged as a 70-year-old white man. We particularly like to lock up black and brown people, right? This whole system is racialized and this whole system is monetized. In Cook County, African American youth are 46 times more likely than white youth to be incarcerated. So all this violence that we're talking about, when we talk about violence at an individual level, we have to think about it in its broader context and there's another kind of violence that we have to talk about. This is Dr. Pearl Farmer. I unfortunately was not able to be here because I was at another conference when he was awarded the McLean Prize a few months ago. This is what Dr. Pearl Farmer says about structural violence. Structural violence is one way of describing social arrangements that put individuals and populations in harm's way. The arrangements are structural because they are embedded in the political and economic organization of our social world. They are violent because they cause injury to people. Neither culture nor pure individual will is at fault. Rather historically given and often economically driven processes and forces conspire to constrain individual agency. Structural violence is visited upon all those whose social status denies them access to the fruits of scientific and social progress. So by that definition we have to think about ourselves and our institution. A lot of times and certainly in the work that Paul Farmer has done, where structural violence happens is racialized. And it's important for us to realize that race doesn't actually exist. While race is a dynamic phenomenon rooted in political struggle it is commonly considered a fixed characteristic of human populations. While it does not exist in terms of human biology, people routinely look to the human body for evidence about racial identity. While it is a biological fiction it is nonetheless a social fact. The traditional concept of race as a biological fact is a myth. Most Americans still believe in the concept of race the way they believe in the law of gravity. They believe in it without even knowing what it is they believe in. And we're in a time right now where our beliefs about race aren't even understood as being about race by some many people. I saw quote, Eric Trump said, my father only sees one color green. So urban black and brown families face a unique set of adversities and stressors. The massive historical traumas of attempted genocide and slavery have never been addressed yet create the context in which present traumas occur and are dealt with. Those of us working with children and families whose daily existence is shaped by the legacy of slavery and racial injustice cannot optimally intervene if we fail to understand and address the effects of the trauma of the past. So just as in cases of individual traumatization avoidance of acknowledging and addressing the traumatic past makes it impossible for integration to occur. As long as historical trauma remains taboo the racial divisions and disparities that pervade every aspect of American life will persist. This is what happens when you have a society that is founded on white supremacy. So this is just a map of shootings in Chicago from 2015. The 2015 is not important. What's important is where the shootings are and where we are. So we're pretty safe over here. Why is that? Just because we're like better people because we don't deserve it. So it doesn't happen. Like why? Yes. Yes. Largest private police force. And you also have resources that are put in place to ensure safety in addition to the private police force. So when resources are deployed to provide safety it's possible to provide safety. By the same token when resources are deployed to provide violence it works. So for Comer Hospital 80% of patients presenting to the ED reside in a 10 zip code area in a 6 mile radius around University of Chicago Medicine. All 10 of these zip codes are home to majority African-American populations with 7 of the 10 being at least 95% African-American. As a whole the population of this 10 zip code area is 87% African-American, 6% white, 6% Hispanic, Latino. And that includes Hyde Perk, right? In contrast to the overall city of Chicago which is 51% female this area is 55% female the result of life expectancy disparities and mass incarceration. Over 35% of the population in this area is below poverty. And unemployment rate at this now it's probably a little bit lower but at that time was 9% more than one and a half times the rate for the rest of the city. So we need to address the injuries that our patients have number one because they have them and we know they have them. Number two if you take the definition of structural violence that Dr. Farmer gives us we are not simply surrounded by it. We are an agent of it. So if we're an agent of structural violence do we have a responsibility to try to correct it? Raise your hand if you live in a community where there's violence happening on a relatively frequent basis. Raise your hand if you know someone who's been injured by the violence going on in your community been shot, stabbed. Raise your hand if you know someone or have a member of your family who's been killed by the violence going on in your community. Okay, thank you. Raise your hand if at some point in your childhood you were offered some kind of support or service to help you cope with that violence. Okay. So there it is, right? I mean it's textbook, right? Fruits of scientific and social progress. Not for them. There are lots of examples of structural violence in Chicago. I'm not going to spend a lot of time on this but this is one of the most racially and economically segregated areas in the United States and this is by design. The educational segregation in this city is so monolithic that they tore up the desegregation decree because there are not enough white children in the school system to desegregate it. There's a long honored tradition of state sanctioned violence in this city. It includes the assassination of Fred Hampton in 1969, an organized police torture ring in the Chicago Police Department for a decade, and then of course our more recent horrors. And then we had that for 30 years. Now to say that we are an agent of structural violence is not to say that we are a bad institution. Any more than to say that the youth that we serve are agents of individual violence says that they are bad people, right? As an institution we had reasons for what we did and we thought they made sense. And now we have reasons for what we're doing and we think they make sense. I'm glad we're doing it. I hope we do it right. Thankfully we have a great leader, Dr. Rogers. So the only way to counter the effects of structural violence is for existing systems to actively work to change and to work collaboratively across systems and disciplines to serve the best interests of their clients. And that is really what we're trying to do in the Healing Her People model. So violent injury is a reoccurring disease. There's lots of research that shows this. And one statistic that's frequently cited is that within five years of a violent injury 40% are going to be injured again and 20% are going to be dead. It also costs a lot of money, this kind of injury, right? These are some Comer numbers. And the important things here are number one, that 93% of children injured by firearms did not die, right? So they're injured and then they're gone to live their life. And also that the average cost for care of those gunshot wound patients is over $75,000. So we spend a lot of money taking care of them, but only certain injuries. There's some data that suggests that these types of intervention, hospital-based violence intervention programs are cost-effective. That is, they don't cost any more than not doing them. And there's some evidence that says they actually save substantial amounts of money. And in the study by our colleagues in Philadelphia, using a base effect of 25% effectiveness, they calculated over five years, depending on how you measured it, savings from anywhere from $82,765 to $4,055,873. So we're going to spend the money one way or another, right? So do we have an ethical obligation to say, if we're going to spend the money anyway, we might as well use some of it to help people recover? This is Dr. John Rich. And Dr. John Rich is the author of Wrong Place, Wrong Time. If you have not read that book, I highly recommend it. And John is the director of the Center for Non-Violence and Social Justice at Drexel University in Philadelphia. And some who came to the community faculty summit here a couple months ago, saw John and Dr. Ted Corbin, who's the medical director of Healing Her People in Philadelphia, speak. They are our colleagues, mentors, teachers, heroes, friends, and we're just trying to be a little bit like them. So John says, a high level of violence in their communities makes young men feel physically, psychologically, and socially unsafe. Physically, young men who've been shot, stabbed, or attacked fear that unless they harm themselves, someone else might attempt to harm them as they have been injured before. Psychologically, they're left with the hypervigilance and disruption that come from trauma. Socially, they have often been raised in communities where there is a shared idea that if you fail to defend yourself when challenged, you become a sucker, which will lead other people who now believe you are weak to take advantage of you. Sadly, because of their social position and the legacy of violence, racism, and poverty into which they have been born, they have become, for many of us, strange icons of fear. Each time a shooting or a stabbing or an assault is reported in the news, the details obscure a young man with a story, a young man with real blood running through his veins. So in John's work that he chronicles in Wrong Place, Wrong Time, his main discovery was this, that much of the risk behaviors that drive violence, both violent injury and violent perpetration, have at their core untreated, unresolved psychological trauma. So there is a cycle of violence that looks a lot like the cycle that I showed earlier with the ACEs study, that people experience something traumatic. They have reactions related to it. Because of those reactions, they do things to manage how they're feeling. That includes often using substances and carrying a weapon. These things increase their risk for injury, re-injury, retaliation. One way out of this cycle is to be dead or locked up. This increases risk for injury. There's injury. They go to the hospital. They get treated in the hospital. There's no attention or little attention paid to the psychological emotional impact of the injury. They get discharged. They're dealing with their traumatization and it goes round and round and round. Makes sense? So the Healing Hurt People model says, when that individual is treated in the hospital, we have an opportunity. We have an opportunity to engage with someone to say, you don't have to deal with this alone. We have support that might help you to manage what you're going through and might help you in your recovery. So Healing Hurt People is a trauma-informed hospital-based violence intervention model developed at Drexel by John, Ted, and Sandy Bloom, who's a psychiatrist who developed something called the Sanctuary Model. At the core of Healing Hurt People is after that initial engagement where we do basic psychoeducation about trauma and emotional support, there is for those who want intensive case management. And that includes working with people around any aspects of their life where they could use some support advocacy assistance. The other core service of Healing Hurt People is self-groups, trauma psychoeducation groups. Self-stance for safety, emotions, managing emotions, loss and letting go, and future. So the goals of the program are to provide trauma-informed care in order to promote recovery and reduce re-injury retaliation and arrest, increase patient's capacity to thrive, and integrate trauma-informed practice in the philosophy of care and core competencies at our hospitals. This is a flow chart that shows you what happens for a patient. So we try to identify them as early as possible and we try to engage them as early as possible. And at that time, talk to them about these are some of the reactions that people have after they get shot. And it's not crazy, it's normal. And here are some things you can do to help manage it. Like we will show them how to do deep breathing to calm down their bodies when they're having re-experiencing reactions or flashbacks or sleep disturbance. If they elect to be involved in a program beyond that, they then work with someone individually who does what I say, everything but psychotherapy, right? And that also includes self-groups. Self-psychoeducation model, as I said, focuses on teaching or mentoring participants regarding safety, emotions, loss in the letting go, and future. These are called psychoeducation groups, but they're really more about communication than they are about education. This is about us talking together and our clients talking with each other about what they've been through and how they're dealing with it. And our groups now are co-facilitated by clients who've been in the program for extended period of time, who are sort of our peer leaders slash alumni. Dan Trell, who was in the video, and his cousin Deshaun, who was in the video, they're two of our facilitators. So our successes with the program so far have been, number one, identifying patients that were embedded in two level one trauma centers, one at Stroger and one here at Comer. And as a result, we are able to find the kids, right? Somebody asked earlier today, how do you recruit your patients? And Carol said, they get shot. That's how we recruit them. So for kids who are in the program for at least six months, there are different outcomes that we track. And these are where we're at with that. And this is data from 74 kids who had at least six months of intensive case management services from the program. And you can see that they're staying safe pretty well. There's low justice system involvement, low retaliation, and increased service utilization. Even some decreases in their depression and PTSD symptoms, even though we're not doing psychotherapy, right? No, we do have partners who do psychotherapy. And that is available to those who want it. The other things that we have are trauma informed care training initiative. We have these lovely lanyards that the funder paid for for that. And we have now six peer leaders or interns who serve as co-facilitators or as members of our trauma informed care training team. And then we have Project FIRE, which is a program that combines glass blowing, glass arts education, mentoring, employment and self-psychoeducation for young people injured by violence. We've had 25 youth to date have participated in the program. So our trauma informed care training initiative, we essentially have five points of trauma informed care for medical providers. We have these beautiful postcards that are going to be ready any day now. So just, you know, come let me know. We'll make sure that they're distributed widely, particularly in our emergency departments. But trying to help providers to remember these points and things that they can do to emphasize safety, screen, understand the context, avoid retraumatization, and plan for discharge. The things that we've had more challenges around our substance use, because that is for many of our kids, the main way that they've been managing their reactions and responses for years from a very young age. And it's actually, certain substances will reduce the risk that they're going to violently injure someone. So we don't want to just say, stop smoking that. It's not helpful. But some who want to be using less, it's a struggle. The geography of the city, which is there's just limited access to safe transportation. It's a very large city. The ongoing threat of extreme violence and other trauma that they're dealing with lack of resources, especially mental health and social services, which are basically not provided to people who don't have money. And disruptions in funding, the easy availability of guns, and then sometimes engaging families that are really oftentimes overwhelmed and not always available. So a lot of the work we're doing is with individual kids and not with the rest of their families. So I'm going to show this quick video about Project Fire, and then we'll have a few minutes for questions. This is Nkosi Barber. He is the mentor instructor for Project Fire. He's an award-winning glass artist. And he's now making a whole line of pendants that you could probably figure out a way to hang him on. Projectfireshy.com, if you want to buy something. It's particularly effective in working with students who've been exposed to traumatic experiences. Partially because of the risk that's involved in working with the material, it's potentially dangerous for working with 2,000 degree molten material. It requires quite a level of trust to be able to work with the material. Learning how to walk again, and try to run again, all that stuff. That was like the worst part. The bullet's still in my leg right now. I've been kind of starting to change my life around. A lot of people I've been losing, a lot of people and stuff like that. The last one asked me to do that because they'll be like, you don't look like you blow glass or something like that, but I can show them better than I can tell them. People look at you different too. He ain't just trying to be out in these streets. He's trying to really do something with his life and stuff like that. My end are both for the students here is that they see other opportunities for themselves in any field, in any medium, in any way. They see a sense of future. So the last thing I want to say is that a lot of times when we are trying to get support for these interventions, there's a poll for people to say, this is the answer, right? If we do this, that will be the answer. So Project Fire is not the answer. Healing Her People is not the answer. Cure Violence is not the answer. Trauma Recovery Centers are not the answer. They're all the answer. And rather than saying one has to be the answer and beat out the others, what we need to be doing is looking at how do we leverage what these different approaches are doing and combine them so that our kids have the best chance of succeeding. And that really is the opportunity that we have here with a new Level One Trauma Center starting from scratch to really bring together all the different answers and then prove that they can be an important piece of solving the problem. That is the expectation. And there is, it looks like some funding, external funding that can support work with people 19 and above at both hospitals. But we are waiting to see what resources are going to be deployed here and how they're going to be deployed. In Philadelphia, is it both? Yeah, it started in Philadelphia as a program for adults. And then they added a pediatric component. Good afternoon. Great presentation. I'm Tony Irving from Gennon, Chicago, and we are a supporter of your work, as you know. Maybe you could tell the group here. The biggest supporter. Pardon? You're the biggest supporter of our work. The biggest, the first, but let's just not throw those terms around. No, just kidding. But most of the data that you have is, I understand, to be self-reported. And maybe you could talk a bit about the long-term strategy around data collection, what it's going to take to do more, and what kinds of evaluation goals you have for the future. Yeah, so another supporter, Chicago Beyond, is funding a collaborative program evaluation project with John Rich and Ted Corbin. Where we will, we hope, be able to dovetail our data with their data. We put so much of our resources into delivering the care that we're not able to collect all of the data that we would like to. So we're hopeful that this will give us more capacity to do that and that we're getting now developmentally as a program to a point where we're in a better position to do that. Carol, do you want to add anything about that? One of the things that, Tony, I know you have taught, we've talked about and over the years is getting kind of longitudinal data. Because most of the programs that serve kids in these hospital-based violence intervention programs, and there are a number of them all around the country, look at a window of six months. And what we're hoping to be able to do is gather data not only while the kids are in the program, but after they've left us and find out what happens to them a year, two years, three years down the road. Because for us to have any kind of real helpful information about how this works, we really need to begin to find out if this works over a longer period of time. And with kids, with teenagers, anybody who's connected with teenagers knows that their behavior is kind of off the chain at best, right? So we have some beginning data of kids who've been in our program for a longer period of time that they really can begin to integrate this, the concepts of safety, emotions, loss and future into the everyday life that they live and go on to do kind of successful productive things. But that's one of the things that we hope to be able to do long-term. And one example of just a data point that the data that we have is really very limited and you can't do a whole lot of interpretation of it is re-injury data. So for people who are not actively engaged in our program, the only way we know about re-injury is if they show up in one of our hospitals. And so we do have 17 level one trauma re-injuries among kids that we've had contact with. But we have no idea about those other kids, they might have gone to a different hospital, they might have gone to Christ, or they might have gone to Northwestern. And so we just don't know. We do know pretty well if they're in the program. And most of those 17 injuries are kids who were not injured while they were in the program. Brad, I'm struck by two things. I'm Michael Masalfer from Developmental and Behavioral Pediatrics. One of which is the context of the stress of parenting. And one of the context is that DCFS is significantly and substantially broken. That's my first kind of comment. And, you know, any things that you see that would help safety and mentoring in contrast to the mass of DCFS, where there are some good people but the gap between quality and stuff you can never predict, and they're overwhelmed and underfunded. So my short answer is that similar to other kinds of problems that our families are facing, if the resources went into providing support to people to deal with whatever's going on, rather than to punish them, we would be a lot better served. My second comment is the context of how early this happens. Everybody kind of thinks that magically childhood is safe and then risk taking starts to escalate as I go through puberty. Your data shows that these kids are probably soldiers before they were born. Some of them are literally born into the streets, into that life. And even for those who weren't, I mean, they're being recruited at very young ages and they're being recruited by older people who are exploiting them and are benefiting from the risk they're taking. But those older people were the younger people who got recruited in. So it's a really pernicious cycle. And I think there's a question up here, so I want to... All right, thank you. Hi, good afternoon. My name is Levine Pettis. A few years ago, Dr. Carl Bells gave a talk at the City Club of Chicago and he mentioned that in order to reduce the violence that we need to create social fabric. And I'm wondering, being a community member, I stay at 6900 South Dorchester, what I can do personally for my community to create social fabric. It's a great question. I think that for me, part of the question is, whose responsibility is it, right? Isn't it all of our responsibility to create social fabric? So I think there are lots of things that any one of us as a member of a community can do to promote peace, to be trauma-informed. Dan Trell is doing it with his music. A lot of it, to me, comes down to advocacy, right? Which a lot of advocacy was done around whether there would be a level one trauma center here. And I think it's also thinking about things in a larger context and not just like, here's this problem and then we're going to address this problem in this way. It is how do we create real community, right? And so where the resources are in the community, are they being shared? Are they being used in a way that promotes that kind of community fabric? So I didn't exactly answer your question, but those are my thoughts about that. Just a quick addition, I'd say that there's data that demonstrates that there's a real correlation between how well people know their community members and the level of violence. And so I would just say to people in the room the most simple thing, because sometimes it seems really difficult, right, that there are these large intractable problems and what can I as an individual do? I would say know who the person is three doors down across the street. Who lives in that house? Her nephew, does she work? The grandmother's sick, whatever the scenario is. But the number one thing that all of us in this room can do is to know the people on our block, understand who they are, be able to address them by name. And there's a direct correlation between that and a reduction of violence. And I think that that's a beginning of placemaking and a foundation upon which all these other things ride. And I'll say just for myself that that really fits with what I do. There are two things I would say that I do as a rule. And one is that I talk out loud about structural violence and the legacy of slavery. The other thing I do is that I speak to people on the street. I acknowledge other humans. That to me goes a long way in terms of what Tony was saying. Hello. My question is very similar. Because a lot of these people who have traumatic experiences tend to come from environments where traumatic experiences are more likely to happen. So I was wondering in addition to healing these individuals, how do we go about adjusting the environment that they live in? Because we can't just simply heal them and then push them back to the exact same environment where they came from. So I guess that goes back to advocacy because right now there is no political will to address the underlying structural issues that we have as a city. And unless we demand it, there will not be. Thank you.